Consumer Telemedicine is Going in the Wrong Direction

Thanks to AmericanWell, TelaDoc and MDLive, consumer oriented telemedicine – sometimes called direct-to-consumer – is getting some well appreciated visibility.  But this type of telemedicine has had little discernable effect toward reducing health care costs and improving quality of care.

The technology for a patient to have a virtual face-to-face session with a clinician is readily available for anyone with a PC or mobile phone, which is nearly everyone.  The impression given in advertising for direct-to-consumer video visits is that this is enough to fulfill the promises of telemedicine.  It’s not and has inadvertently put consumer oriented telemedicine on the wrong track.

Telemedicine has long promised to reduce health care costs and improve quality of care.  It can do that if effort is re-directed.

  1. Specifically target the highest cost areas.  Two of the biggest targets are hospitalizations and Emergency Room (ER) visits.
  2. Use health care providers local to the patients.  Considering the target areas, this means any hour of any day (24/7) coverage is needed.  In general, this will require cooperation between local physician practices and Urgent Care clinics.  Also, Home Care Agencies (HCA) may be involved.
  3. Again considering the target areas, medical devices, not just video, must be available at the patient end of a telemedicine session.

High Cost Areas

It is estimated that 20% of the population in the US accounts for 80% of overall health care spending.  Not surprisingly, hospitalizations and emergency room (ER) visits stand out as the most costly areas.  The average cost for a hospitalization is $10,000 per day with an average stay of 4 days.  The average ER visit costs $1.2K and there are a lot of them.  Focusing on reducing hospitalizations and ER visits can get the best return on effort.

There is compelling evidence revealing a critical element toward achieving that objective.  A program in Houston put telemedicine in the hands of paramedics so when they arrive at the scene of an emergency, they can immediately conduct a telemedicine visit for an injured party.  Last year when they conducted their 10,000th patient encounter, they had prevented 6,000 unnecessary ER transports.  (Average cost of the telemedicine visits was $220 and the average cost of an ER transport was $2,200.)  Getting clinical assistance delivered quickly to the patients via paramedics with telemedicine was the basis of that savings.  Although we can’t quantify it, it is intuitively obvious that if the patients already had telemedicine equipment on site, in some cases there wouldn’t be need for a paramedic.

Many hospitalizations are due to acute problems not being treated promptly allowing symptoms get out of hand.  Not treating chronic disease issues in a timely manner can also result in hospitalizations that could be avoidable if problems were dealt with immediately.

A critical factor in reducing hospitalizations and ER visits centers on the immediacy of delivering clinical care.  The most immediate care possible is to “virtually” get the clinician to the patient with key medical devices to make an assessment.  Telemedicine is the enabler for this.

Provider Cooperation and Availability

Telemedicine uniquely offers the opportunity for immediacy in the delivery of health care.  When a patient experiences what he/she feels is an urgent need for the services of a clinician, satisfying that need quickly benefits the patient short term and if that care avoids follow-on issues, in the long term as well.  For this to occur:

1)   the patient needs ready access to telemedicine equipment and

2)   there must be an available clinician to provide care at that time.

Not unexpectedly, a significant percentage of ER visits occur outside of normal physician office hours.  To handle that, the health plan must include telemedicine access to Urgent Care clinic services during evening hours and weekends.  Both normal working hour access to a primary care physician practice and out-of-hours access to an Urgent Care clinic must be part of the patient’s telemedicine health plan.  While such cooperation between health care providers may be relatively easy in some areas, it could be challenging in others, a challenge Third Party Administrators (TPA) and employers will have to meet.

Home care agencies (HCA) play a role in avoiding re-hospitalizations after a patient is discharged.  Under relatively new rules, if a patient is re-admitted within 30 day of a discharge, the hospital gets penalized.  So it is common for specified categories of discharged patients to be covered by home care services during that period.  Due to improved incentives, telemedicine is increasingly used as part of the home care service.  Use of telemedicine for discharged patients has been demonstrated to reduce re-admittances.

Aside from helping to reduce re-admittances, HCAs have the potential of playing a role in reducing initial hospitalizations and ER visits for certain acute and chronic conditions.  It is reasonable to expect that expanded use of telemedicine could reduce the number of visits where a nurse would drive to a patient’s home.  The key for this is that the telemedicine equipment must be inexpensive and the HCA receive compensate commensurate with the services rendered.  Involving HCAs in a telemedicine oriented health plan is a new concept, but worth pursuing.

Availability of Telemedicine with Medical Devices to the Patient

Video-only consumer telemedicine using smart phones has fallen short in providing even the minimum medical devices used in a typical physician’s office visit.  The profile of a consumer making a video call to one of the current direct-to-consumer telemedicine companies is not the same as the profile of a high utilizer of clinical services.  Getting a prescription for a bad cough with a video call is convenient and inexpensive.  It doesn’t exceed the limitations of a video call and it is not important that the clinician doesn’t know the medical history of the patient.

For a person with a chronic condition (e.g. COPD, CHF, Diabetes), knowing that person’s medical history is important and being able to use medical devices (e.g. stethoscope, blood pressure meter) on the person is important.  This is the category of individuals most likely to be hospitalized or go to the ER.

The more people who are at-risk and who have a telemedicine station with appropriate medical devices, the greater the likelihood of avoiding a hospitalization or ER visit.  The equipment could be made available similar to durable medical equipment (DME) or directly purchased by the consumer.

Will 2019 be the Year Consumer Telemedicine Finally Takes Off?

We are two thirds the way through 2018 and there have been a few hints that 2019 may be the breakthrough year for true consumer telemedicine. While the growth of video visits is encouraging, the demand we are seeing from employers such as Amazon/JP Morgan/Berkshire may just be the impetus needed to push things forward. We are hopeful that 2019 may be the Year of Telemedicine using a win-win-win solution for payers, providers and patients.